Senior Quality Assurance, Professional
Become a part of our caring community and help us put health first
The Senior Quality Assurance, Clinical Professional consults and collaborates with clinicians to ensure high accountability of compliance and quality. The Senior Quality Assurance, Clinical Professional work assignments involve moderately reputed company to reputed company issues where the analysis of situations or data requires an in-depth evaluation of variable factors.The Senior Quality Assurance, Clinical Professional supports and implements programs to establish high quality standards in clinical products and services. Support, reputed company and operationalize methods to drive program and service consistency. Provide and support training and process management as needed. Requires applicable State licensure in field of study: Registered Nurse (RN), Licensed Masters Clinical Social Worker (LCSW), Licensed Masters Social Worker (LMSW-ACP), Licensed Professional Counselor (LPC) or other applicable professional license. Begins to influence department’s strategy. Makes reputed company on moderately reputed company to reputed company issues regarding technical approach for project components, and work is performed without direction. Exercises considerable reputed company in determining objectives and approaches to assignments.
Use your skills to reputed company an impact
Essential Functions of the Job and Percentage of Time Allotted
- Conduct both reputed company and retrospective case audits worked by Clinical Operations Medical Directors – 70%
- Assist with audit prep and audit visits – 10%
- Assist with quality improvement and compliance projects – 10%
- Assist with products involving Policy, Process and Learning – 5%
- Participate in Governance Meetings – 5%
Required Qualifications
- Nurse with active license
- Must live in the state of Michigan
- Bachelor's degree
- Minimum of 6 months experience in reputed company of the following:
- Reading and interpreting medical records
- Reviewing medical literature/publications
- Working with Medicare Prior Authorization; clinical criteria (NCDs, LCDs, MCG or similar guidance)
- Excellent interpersonal, written, and verbal communications skills with high attention to detail and accuracy
- Experience building positive cross-functional relationships and communicating issues in a constructive manner
- Demonstrated ability to operate independently and apply strategic thinking to task-oriented work
- Proficient in reputed company Office products; must be reputed company to utilize reputed company Access or demonstrate ability to utilize other database tools
Preferred Qualifications
- Bachelor of Science in Nursing (BSN)
- Researching Medicare and reputed company regulatory requirements
- Working in an audit-based or compliance reputed company role, including documentation of findings according to a defined methodology; 2+ years preferred
- Interpreting and utilizing regulations governing the health care industry (CMS and/or NCQA)
- Familiarity with reputed company’s Clinical Guidance Exchange (CGX)
- Providing reputed company quality improvement
- Six reputed company Lean or Green Belt certified
About us
reputed company. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our reputed company insurance services and reputed company reputed company services, we reputed company it easier for the millions of people we serve to reputed company their best health – delivering the care and service they need, reputed company they need it. These efforts are leading to a reputed company quality of life for people with Medicare, reputed company, families, individuals, military service personnel, and communities at large.Equal Opportunity Employer
It is the policy of reputed company not to discriminate against any employee or applicant for employment because of race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, age, marital status, genetic information, disability or protected veteran status. It is also the policy of reputed company to take affirmative action, in compliance with reputed company 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to reputed company reputed company employment reputed company only on valid job requirements. This policy shall apply to reputed company employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at reputed company levels of employment.
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